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THE FOLLOWING THE FOLLOWING LECTURELECTURE HAS BEEN HAS BEEN
APPROVED FORAPPROVED FOR
ALLALL STUDENTS STUDENTS
This lecture may contain information, ideas, concepts and discursive anecdotes that may be thought provoking and challenging
Any issues raised in the lecture may require the viewer to engage in further thought, insight, reflection or critical evaluation
Clinical Clinical CommunicationCommunication
Professor Craig JacksonProf. Occupational Health Psychology
Head of Psychology BCU
Clinical Communications OutlineClinical Communications Outline
Benefits for clientsBenefits for clients
Benefits for cliniciansBenefits for clinicians
DemeritsDemerits
SkillsSkills
Shut up and listenShut up and listen
Clinical Communications OutlineClinical Communications Outline
““The good clinician treats the The good clinician treats the disease, but the great clinician disease, but the great clinician treats the patient”treats the patient”
William Osler William Osler
Relatively new areaRelatively new area
Communication was a “wet skill”Communication was a “wet skill”
Now part of curriculumNow part of curriculum
Seen as important ( not more important than clinical skill) . . .Seen as important ( not more important than clinical skill) . . .
. . . Clinical skills viewed as worthless without communication. . . Clinical skills viewed as worthless without communication
Communication skills not universalCommunication skills not universal
Different types of communication Different types of communication
Depends on therapists’ Depends on therapists’ TrainingTrainingPhilosophyPhilosophyinclinationinclinationTheoretical positionTheoretical position
PsychodramaPsychodrama
Holotropic breathworkHolotropic breathwork
CBTCBT
RETRET
““Hello Chris”Hello Chris”
Covert naturalistic experimentCovert naturalistic experiment
8 sessions with psychotherapist8 sessions with psychotherapist
Was NOT psychotherapyWas NOT psychotherapy
Pseudo hypnotherapyPseudo hypnotherapy
DistractionsDistractions
. . . . . iPad. . . . . iPad
Not the “breathy voice” againNot the “breathy voice” again
Sounds too “American”Sounds too “American”
. . . Too controlled. . . Too controlled
. . . Too therapeutic. . . Too therapeutic
. . . Too effortful. . . Too effortful
. . . Not naturalistic. . . Not naturalistic
Benefits for Clinicians & ClientsBenefits for Clinicians & Clients
Time savingTime saving
Effective & efficientEffective & efficient
Reduces Stress & BurnoutReduces Stress & Burnout
Reduces litigationReduces litigation
Clients more satisfiedClients more satisfied
Best predictor of resolutionBest predictor of resolution(e.g. Chronic headache; Headache study group Ontario (1986)(e.g. Chronic headache; Headache study group Ontario (1986)
Shorter care neededShorter care needed(coronary care patients with emotional support - 2 days less bed time)(coronary care patients with emotional support - 2 days less bed time)Mumford et al 1982Mumford et al 1982
Benefits for ClientsBenefits for Clients
Positive evaluationsPositive evaluations
Both Clinician and Client agree on reason for consultationBoth Clinician and Client agree on reason for consultation
Clinician asks client about ideas, concerns or health beliefsClinician asks client about ideas, concerns or health beliefs
Clinician takes time to achieve a shared understanding with clientClinician takes time to achieve a shared understanding with client
Positive consultations take no longer than negative onesPositive consultations take no longer than negative ones(Arborelius & Bremberg 1992)(Arborelius & Bremberg 1992)
Improved outcomesImproved outcomes
A Meeting of ExpertsA Meeting of Experts
Any clinical consultation is a meeting of two expertsAny clinical consultation is a meeting of two experts
ClinicianClinician - Skills & Knowledge- Skills & Knowledge
ClientClient - Their body & Experience- Their body & Experience
But sometimes, people just want to be told what to do . . . But sometimes, people just want to be told what to do . . .
It’s all subjective of courseIt’s all subjective of course
Clients rating their cliniciansClients rating their clinicians
Not knowledge basedNot knowledge based
Not skills basedNot skills based
Based on communication and subtle cuesBased on communication and subtle cues
They might be wrong . . . but their perception is everythingThey might be wrong . . . but their perception is everything
MedspeakMedspeak
JargonJargon
Sets boundaries - reminds of power relationshipsSets boundaries - reminds of power relationships
Lay personLay person ClinicianClinician
““Sick”Sick” IllnessIllness Vomit Vomit ““Nerves”Nerves” AnxietyAnxiety NeurologyNeurology““Chronic”Chronic” SevereSevere Long durationLong duration““Acute”Acute” SevereSevere Sudden onsetSudden onset““Diet”Diet” Calorie restrictionCalorie restriction IntakeIntake““Drugs”Drugs” NarcoticsNarcotics MedicationMedication““Stomach”Stomach” AbdomenAbdomen OrganOrgan““HistoryHistory““ The pastThe past Previous diseasePrevious disease
Interruptions & Redirections Interruptions & Redirections
Consultations start with clientConsultations start with client
Appearing rushedAppearing rushed
Checking watchChecking watch
FidgetingFidgeting
Monitoring emailMonitoring email
28% of clinicians interrupt client in first opening28% of clinicians interrupt client in first openingMean of 23 seconds (Mean of 23 seconds (Marvel et al 1999Marvel et al 1999) )
Average of 2 interruptions per consultationAverage of 2 interruptions per consultationMean of 12 seconds in home consultations (Mean of 12 seconds in home consultations (Rhoades et al 2001Rhoades et al 2001))
Valerie: HIV patient in 1985Valerie: HIV patient in 1985
Useful sourcesUseful sources
90% of info comes from taking a history90% of info comes from taking a history
10% (or less) from case files and records10% (or less) from case files and records
Visual metaphor Visual metaphor
Might come in bits and piecesMight come in bits and pieces
Communication Skills: General MannerCommunication Skills: General Manner
1.1.Responds to cuesResponds to cues
2.2.Active ListeningActive Listening
3.3.Use EmpathyUse Empathy
4.4.Offer SupportOffer Support
5.5.Non-judgementalNon-judgemental
6.6.Avoid personal beliefsAvoid personal beliefs
7.7.Simple languageSimple language
8.8.Use appropriate body languageUse appropriate body language
9.9.Questioning styleQuestioning style
10.10.Information givingInformation giving
11.11.Information gatheringInformation gathering
Information GatheringInformation Gathering
Appropriate languageAppropriate language
Ordered and MethodologicalOrdered and Methodological
Comprehensive / SuccinctComprehensive / Succinct
CoaxingCoaxing
Use triangulation . . . “So you said that . . . Therefore . . .”Use triangulation . . . “So you said that . . . Therefore . . .”
Offer partners or collaborators to inputOffer partners or collaborators to input
Props e.g. clipboard, notes, questionnaireProps e.g. clipboard, notes, questionnaire
Information Gathering . . . Don’t rely on symptomsInformation Gathering . . . Don’t rely on symptoms
““Doorknob concerns”Doorknob concerns”
““By the Way” syndrome (By the Way” syndrome (Robinson 2001Robinson 2001))
Clients often reveal real reason only when comfyClients often reveal real reason only when comfy
Real reason is not the first reason hey giveReal reason is not the first reason hey give
Psychosocial issuesPsychosocial issues
Worries about futureWorries about future
Their own ideasTheir own ideas
Social context of their problemSocial context of their problem
Barry et al 2000Barry et al 2000
Information GivingInformation Giving
Convey info Convey info
Check understandingCheck understanding
Control of consultation (allows it to vary)Control of consultation (allows it to vary)
Signpost change of directionSignpost change of direction
Summarises / indicates next stepsSummarises / indicates next steps
Recognise and respond to client’s concerns and anxietiesRecognise and respond to client’s concerns and anxieties
Consultation General SkillsConsultation General Skills
1.Gives name and explains role; checks patient’s name 2.Gives greeting appropriate to culture (handshake not always needed)3.Non-verbal behaviour appropriate to culture (eyes not always needed)4.Establishes purpose of interview 5.Clarifies why interview is taking place:
- from client’s perspective - from clinician’s perspective
6.Checks that patient is happy to proceed 7.Establishes desired outcome of interview 8.Establishes baseline knowledge/understanding 9.Uses open questions 10.Listens 11.Confirms what s/he has learned 12.Signals move to information-giving at end
Some natural cynicism from medical circlesSome natural cynicism from medical circles
Date Symptoms Referral Investigation Outcome
1980 (18)1980 (18) Abdominal painAbdominal pain GP --> surgical OPGP --> surgical OP AppendictomyAppendictomy NormalNormal
1983 (21)1983 (21) PregnancyPregnancy GP --> obs and gynae GP --> obs and gynae Termination Termination(boyfriend in prison)(boyfriend in prison) OPOP
1985-71985-7 Bloating, abdominal Bloating, abdominal GP --> Gastro andGP --> Gastro and All tests normalAll tests normal IBS diagnosisIBS diagnosis(23-25)(23-25) blackouts (divorce)blackouts (divorce) neurology OPneurology OP unexplained syncopeunexplained syncope
1989 (27)1989 (27) Pelvic painPelvic pain GP --> obs and gynaeGP --> obs and gynae SterilisedSterilised Pain persists for 2 yearsPain persists for 2 years(wants sterilisation)(wants sterilisation) OPOP
1991 (29)1991 (29) FatigueFatigue GP --> infectiousGP --> infectious Nothing abnormalNothing abnormal Diagnosis of ME by patientDiagnosis of ME by patientdiseases unitdiseases unit and self help groupand self help group
1993 (31)1993 (31) Aching musclesAching muscles GP --> rheumatologyGP --> rheumatology Mild cervical Mild cervical Pain clinic - TryptizolPain clinic - Tryptizolclinicclinic spondylosisspondylosis
1995 (34)1995 (34) Chest pain, breathlessChest pain, breathless A&E --> chest clinicA&E --> chest clinic Nothing abnormalNothing abnormal Refer to psychiatric servicesRefer to psychiatric services(child truanting)(child truanting) poss hyperventilationposs hyperventilation
Case Summary of a counselling clientCase Summary of a counselling client
SummarySummary
Clinicians expected to be good communicatorsClinicians expected to be good communicators
Clinical skill does not make up for communication lackingClinical skill does not make up for communication lacking
Communication does not replace clinical skillsCommunication does not replace clinical skills
Getting it right worthwhileGetting it right worthwhile
Rewards Rewards
Getting it right takes time and experienceGetting it right takes time and experience
Clinical supervision essentialClinical supervision essential
Case reviews essentialCase reviews essential
Communication without KnowledgeCommunication without Knowledge
Communication without KnowledgeCommunication without Knowledge
Some ReferencesSome References
Makoul, G. (2001). Essential elements of communication in medical encounters: Makoul, G. (2001). Essential elements of communication in medical encounters: the Kalamazoo consensus statement. the Kalamazoo consensus statement. Academic Medicine, Academic Medicine, 76(4)76(4): 390-393.: 390-393.
RSM forum on Communication in Healthcare (2004). Core curriculum for RSM forum on Communication in Healthcare (2004). Core curriculum for communication skills in medical schools. In E. McDonald (ed). communication skills in medical schools. In E. McDonald (ed). Difficult Difficult Conversations in Medicine.Conversations in Medicine. Oxford: Oxford University Press. pp 209-211. Oxford: Oxford University Press. pp 209-211.
Simpson, M et al. (1991). Doctor-patient communication: the Toronto consensus Simpson, M et al. (1991). Doctor-patient communication: the Toronto consensus statement. statement. British Medical Journal. British Medical Journal. 303(6814): 303(6814): 1385-1387.1385-1387.
Von Fragstein, M. et al. (2008) UK consensus statement on the content of Von Fragstein, M. et al. (2008) UK consensus statement on the content of communication curricula in undergraduate medicine education. communication curricula in undergraduate medicine education. Medical EducationMedical Education 42(11): 42(11): 1100-1107.1100-1107.
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